RN Sr. Auditor-High Cost Claims Unit

With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.

Detroit, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="https://www.bcbsm.com/" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="http://www.bcbsm.com/index/about-us/our-company.html" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />Learn more about your options as an external candidate. <a href="https://bcbsm.taleo.net/careersection/2/jobsearch.ftl?lang=en" target="_blank" rel="noopener noreferrer">Click here</a> to view open positions. http://www.bcbsm.com

keywords: analysis,teamwork,management,support,performance,leadership,document,department preferences,knowledge and skills,license


Competitive Total Compensation Package

Overview: Responsible for assisting and supporting in the evaluation, recommendation, establishment, implementation and analysis of new and improved production workflows, work processes for systems, reporting, and new products/programs to improve customer service levels and overall quality.
Responsibilities: <ul> <li>Review of medical records.</li> <li>Perform clinical reviews with knowledge of body systems, anatomy and physiology.</li> <li>Assist and support in the planning, coordination, developing and implementing of approved audit programs to enhance the overall efficiency of operational procedures, methods, controls and performance.</li> <li>Analyze, process and/or expedite operational transactions; this may include timely resolutions of problems.</li> <li>Participate in systems testing, develop procedures and controls and provide recommendations for the ongoing improvement of the updated process.</li> <li>Provide leadership team with status of projects, issue, communicate and recommend policy decisions to achieve project objectives.</li> <li>Utilize and maintain available corporate production and reporting systems; produce routine and non-routine reports, presentations, letters, communications and graphics.</li> <li>Assist internal and external personnel by answering questions and supplying information. Develop and maintain effective working relationships with customers and partners.</li> <li>Conduct and oversee training of current and new staff.</li> <li>Review letters and reports of audit staff for accuracy and completeness.</li> <li>Complete special assignments and projects as assigned.</li> <li>Serve as back up to Team Leader as needed.</li> <li>Other duties may be assigned.</li> </ul> <p><strong>Departmental Summary:</strong></p> <ul> <li>Under general supervision&nbsp;the HDC Unit nurse auditor is responsible for assessment and documentation of member utilization and prediction of future spend feeding internal and external customer reporting.</li> </ul> <p><strong>ESSENTIAL DUTIES AND RESPONSIBILITIES&nbsp;</strong>include the following. Other duties may be assigned.</p> <ul> <li>Analyze utilization data from provided sources to evaluate cost drivers.</li> <li>Apply clinical knowledge, incorporating the persistency score to determine if member care needs will be ongoing versus an acute episodic.</li> <li>Apply knowledge of customer benefit structure to determine appropriate use of services.</li> <li>Collaborate with multi-disciplinary team to determine if there are other resources; BCBSM programs, community resources that can curtail benefit spend or improve outcomes.</li> <li>Document findings in a manner that can be consumed by internal process for reporting purposes, internal and external customers.</li> <li>Refer the member to appropriate internal BCBSM group to manage and coordinate care as indicated.</li> <li>Continue to evaluate the member&rsquo;s benefit spend according to Key Decision Criteria.</li> </ul>
Requirements: <p><strong><u>Department Preferences</u></strong></p> <p><strong>EDUCATION AND/OR EXPERIENCE</strong></p> <ul> <li>Bachelor Degree in health-related field preferred.</li> <li>Four to seven years&rsquo; experience in related field.</li> <li>Two consecutive years&rsquo; experience as an analyst or auditor in Utilization Review.</li> <li>Experience in operational analysis, data analysis and problem resolution types of activities.</li> <li>Ability to work independently with minimal direction.</li> <li>Experience with working in the CareAdvance platform is preferred.</li> </ul> <p><strong>QUALIFICATIONS</strong></p> <ul> <li>Current, unrestricted state of Michigan RN licensure.</li> </ul> <p><strong>Qualifications</strong></p> <ul> <li>Thorough understanding of medical coding (CPT-4 HCPCS ICD-9 or DRG) as it relates to audits.</li> <li>Ability to plan, organize direct and control projects.</li> <li>Excellent written and verbal communication skills.</li> <li>Ability to lead and contribute to process improvement projects.</li> <li>Working knowledge of PC applications and/or mainframe preferred.</li> <li>Other related skills and/or abilities may be required to perform this job.</li> </ul>